Provider Demographics
NPI:1972909927
Name:ST.JUDE HERITAGE MEDICAL GROUP
Entity type:Organization
Organization Name:ST.JUDE HERITAGE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMIREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-835-2724
Mailing Address - Street 1:1010 W LA VETA AVE STE 710
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4306
Mailing Address - Country:US
Mailing Address - Phone:714-835-2724
Mailing Address - Fax:714-835-2753
Practice Address - Street 1:1010 W LA VETA AVE STE 710
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4306
Practice Address - Country:US
Practice Address - Phone:714-835-2724
Practice Address - Fax:714-835-2753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86364174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB214168Medicare PIN